P0149 - Safe and Effective Care for Children with Medical Complexity and Technology Dependence: Improving Pediatric Resident Care Coordination Documentation in Continuity Clinic

Background: Children with medical complexity and technology dependence (CMC-TD) have significant health care and care coordination needs, with increased risk for medical errors. Standardizing pediatric resident documentation for these patients may help to improve patient safety.


Objective: To increase the percentage of patients with care coordination notes containing specific documentation on technology from a baseline of 8% to a target goal of 55% among CMC-TD in a pediatric resident continuity clinic.

Methods: From July 2018 to Dec 2019, we assessed the monthly percentage of CMC-TD clinic patients with electronic health record (EHR) documentation of care coordination notes in an urban, hospital-affiliated, pediatric resident continuity clinic. We included patients with ostomies, feeding tubes, tracheostomies, or ventricular shunts. Ishikawa cause and effect analysis was performed to identify barriers. With input from multiple specialists, we developed a SmartPhrase template for care coordination notes to prompt relevant clinical details. Plan-do-study-act (PDSA) cycle interventions included: distribution of a clinic handbook with a new section on documentation and care of CMC-TD, handout detailing how to open care coordination notes, and individualized patient lists provided to each continuity clinic group with email reminders on documentation. T-test was performed to assess for pre-post differences. Statistical process control (SPC) analysis was performed.

Results: We identified 69 CMC-TD patients. Key barriers to resident documentation for CMC-TD included no standardized documentation policy in clinic, lack of knowledge on how and what to document, and time constraints (Figure 1). The percentage of patients with completed care coordination notes increased pre-post intervention from 8.9% to 18.8.% (p<0.001). SPC analysis demonstrated significant process change two months prior to starting the intervention, likely reflecting spillover during the planning phase (Figure 2).

Conclusions: The initial phase of this quality improvement project showed a significant increase in documentation for CMC-TD with development of a SmartPhrase template, educational materials, and individualized patient lists, although our target goal was not achieved. Next steps include visual reminders on huddle boards and personalized reminders with individualized patient lists to continue to improve documentation and patient safety for CMC-TD.